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Pakistan Journal of

Neurological Sciences (PJNS)


Volume 12 | Issue 3 Article 6

December 2017

A silver lining in the dark clouds: Medical


Marijuana, in the Neurological disorders and its
future in Pakistan.
Qamar Zaman
Shifa International Hospital, Islamabad

Maimoona Siddiqui
ShifaTameer -e- Millat University, Islamabad

Follow this and additional works at: https://ecommons.aku.edu/pjns


Part of the Neurology Commons

Recommended Citation
Zaman, Qamar and Siddiqui, Maimoona (2017) "A silver lining in the dark clouds: Medical Marijuana, in the Neurological disorders
and its future in Pakistan.," Pakistan Journal of Neurological Sciences (PJNS): Vol. 12 : Iss. 3 , Article 6.
Available at: https://ecommons.aku.edu/pjns/vol12/iss3/6
REVIEW ARTICLE

A silver lining in the dark clouds: Medical Marijuana,


in the Neurological disorders and its future in Pakistan.

Qamar Zaman1, Maimoona Siddiqui2


1
FCPS (Neurology), Specialty certified in Neurology.Neurologist, Shifa International Hospital, Islamabad
2
FCPS (Medicine), FCPS (Neurology). Associate Professor of Neurology, ShifaTameer -e- Millat University, Islamabad

Corresponding to: Maimoona Siddiqui, Associate Professor of Neurology, ShifaTameer -e- Millat University, Islamabad., Email:drmsid@gmail.com

Date of submission: April 11, 2017 Date of revision: May 25, 2017 Date of acceptance: June 16, 2017

ABSTRACT

Marijuana has been included in the list of illicit drugs for a long time despite its use as a remedy for several medical
problems. However this use has been on the basis of the individual experiences with no concrete scientific
evidence. Its positive effects have been mostly overshadowed by its recreational use worldwide. It has recently
become the topic of hot debate due to several studies showing its role in various medical and especially
neurological disorders. These new findings have created a controversy and world is still divided on its legalization
for medicinal purpose. Several countries and states have legalized it recently, but many experts have raised
concerns about its misuse and long term legal, ethical, financial and health implication, that need to be answered
yet. Pakistan is considered as one of the largest cannabis producing country and with increasing evidence for
potential medicinal benefits; we need to develop a consensus on this topic, considering health, legal and ethical
perspectives linked to its medical uses in our society.
KEY WORDS:Marijuana, Epilepsy, legal, cannabiniods.
ABBREVIATIONS:(THC)Tetrahydrocannabinol .FDA( Federal Drugs Agency )

ALS( Amyotrophic Lateral Sclerosis )

INTRODUCTION: countries including Holland, Germany, Spain France,


To date, about 86 Cannabinoid compounds have Colombia, Czech Republic, Canada have legalized
been identified in nature and some other are its use for medicinal purpose.According to a study, in
synthesized chemically. They have been mostly used USA about 17% of past-year marijuana users
for recreational purposes with major psychoactive reported its use for medical purposes recently3.
ingredient being delta-g-tetrahydrocannabinol (THC)
and some of these compounds like dronabinol and U S E S O F C AN N ABI N O I D S I N VAR I O U S
nabilone have been used as prescription drugs1. NEUROLOGICAL DISORDERS:
Cannabis has been used for various therapeutic Currently, pill form of “dronabinol” and “nabilone”
purposes for thousand of the years. Initially it was has received FDA approval only for nausea caused
grown as an agricultural crop called Hemp, in China by chemotherapy and to increase the appetite of
which then traveled through Asia into Middle East and people with AIDS 4. Various studies have shown its
Africa where it was used for pain and other various beneficial effects in several neurological disorders
conditions like gout, malaria, Rheumatism, and poor recently. For some indications, significant data has
memory for a long time alongside its use for been found to recommend its use where traditional
recreational purposes as well2. therapies were not found to be effective while for
In 1970, it was categorized as Schedule 1 drug and several other disorders its use is still on the
was listed as having no accepted medical use and experimental basis and we still have insufficient
further research was restricted until recently where it evidence to use it.
was found to be of several uses and less side effects
than previously documented2 . These findings have
lead to its legalization for medical purposes in April 1. INDICATIONS WITH GOOD EVIDENCE:
2015 in about 23 states of USA. Several other Epilepsy: Dronabinol and Nabilone have been

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found beneficial in various childhood onset epilepsies outcomes and in dopa related dyskinesiaswith mixed
including Dravet and Lennox-Gastaut syndromes results11. Evidence is needed for its recommendation
that are resistant to the traditional therapies. Their for these and target symptoms (e.g. dystonia,
addition may reduce median monthly seizure psychosis, sleep) related to Parkinson's disease.
frequency by about 36.5%5. They were also found Huntington's disease:Although limited data is
useful in the management of super refractory status available to recommend its use in Huntington's
epilepticus6. But we still need evidence to recommend disease but various case series and small studies
it as alternative to traditional antiepileptics in more showed significant improvements in chorea and the
common epilepsies and as a first line agent in drug neuropsychiatric symptoms in patients with
resistant epilepsies. Huntington's disease. Further large scale studies
Multiple Sclerosis:Cannabinoids (nabilone and may be needed to find its usefulness for these
nabiximols) have been found useful for various indications11.
symptoms of multiple sclerosis like pain, spasticity Dystonia: Data for its use in dystonia is limited to few
and urinary dysfunction7. Although these indication small randomized placebo-controlled clinical trials
have not got FDA approval, health agencies like with mixed results. Further large studies are needed
American Academy of Neurology (AAN) recommend to clear its role11.
that it can be considered in suitable patients as (Amyotrophic Lateral sclerosis (ALS): Some studies
alternative to typical therapies8. showed that theymight be helpful in some aspects in
Neuropathic and other type of pain:These may ALS patients like delaying the onset of ALS and
provide effective analgesia in conditions that are slowing the progression. Thesemight also help to
refractory to other treatments including refractory manage pain, appetite loss, depression, sleep
neuropathic pain cause by diabetes mellitus, central problems, spasticity and drooling 14. However more
neuropathic pain, pain in cancer patients, and in HIV- evidence is needed for recommendation of its use in
positive patients. According to a study about 90% of ALS.
patients reported an improvement in nerve pain after Migraine: They have been found to inhibit pain
cannabis use9. Several guidelines recommend its use response in migraine patients, but clinical trials are
when traditional therapies are not helpful. needed to recommend its use for this indication 15.
Depression and anxiety: Data about anxiety Prion disease: On the experimental basis they have
suggested a greater benefit of cannabinoids shown to reduce the risk of prion disease and protect
(dronabinol, nabilone, and nabiximols) than placebo from prion toxicity but still need to be tested
and can be consider for suitable patients10. However clinically16.
no difference between cannabinoids and placebo in Stroke: They seem to reduce the infarct size and
outcomes of depression was seen and some reported improve functional, histological and neurobehavioral
a negative effect at high doses. recovery but no large scale data is available for its
Tics and Tourette syndrome:There is insufficient recommendation17.
Sleep disorders: There was some evidence that
evidence to support or refute the clinical use of
cannabinoids may improve sleep in some patients.
cannabis for tics. However, it could be an option in Cannabinoids were associated with a greater
resistant cases as positive effects of THC were seen average improvement in sleep quality and sleep
in few studies11. disturbance than the placebo18. Further large scale
studies are needed to find its benefit for this purpose.
Other uses: Some studies have shown its anti tumor
2 . I N D I C AT I O N S W I T H BE N E F I T S BU T activity, as it showed to inhibit growth of the cancer
INSUFFICIENT EVIDENCE: cells. Its benefits have also been observed in Spinal
Dementia:Recently few studies have found that cord injury and Fibromyalgia as well19.
tetrahydrocannabinol and other compounds may
Despite significant positive data, several factors pose
reduce B-Amyliod in the brain12. A recent study has a challenge to its use as a medicine. These include
concluded that cannabis extract containing THC can Medical, ethical and legal and economical factors.
relieve various cognitive and psychiatric symptoms of Medically it is found to be much safer to traditional
Alzheimer's diseaseand found them to be safe and pharmacological agents and addictive potential of
cannabis is quite low. The risk of dependence on
promising treatment option13.However more data is
cannabis is reported to be 9% in long-term users,
required for its use in dementia clinically. significantly less than the addic on rates of heroin,
cocaine, alcohol, and prescribed anxioly cs20 Its side effect
Parkinson's disease:It has been studied in the profile includes euphoria, disorienta on, drowsiness,
context of improving motor features, functional dizziness, motor in coordina on, and poor concentra on.

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The peripheral adverse effects include tachycardia, REFERENCE:
hypotension, conjunctival injection, bronchodilation,
muscle relaxation, and decreased gastrointestinal 1.
motility. Long term effects include risk of psychiatric
disorders, apathy and cognitive impairment and
hazards related to pregnancy21. So its use should be
based on the benefit outweigh the risk assessed by 2.
an expert.
Ethically in various cultures a negative image is linked
to its use and possession. Good awareness 3.
campaign may help patients, their families and
societies to make a decision based on evidence and
knowledge. Ultimately, the medical cannabis debate
is not about making it widely available for a broad 4.
range of health conditions but about giving a small
number of patients an option where they may have
none.
Legally in Pakistan under The Anti-Narcotic policy
201022, person may get punishment up to 6 months on 5.
possessing the cannabis, but still it is the most
commonly used drug with prevalence of recreational
use being 3.6 % in our population23. Due to increasing
argumentation for its use for medicinal purpose, like 6.
the other many developed countries law
amendments will be needed for relaxation regarding
its use for medicinal purpose in Pakistan.
Various necessary measures should be taken for its
controlleduse that may include:
7.
(1) Only be prescribed by experts.
(2) Specific registered points with monitoring
units to monitor the dose or amount each
time. 8.
(3) Regular follow ups by experts to monitor side
effects and check the possibility of misuse.
(4) When to stop or taper the use in case of
negative effects.
9.
Law amendments will be important as there is risk
that if its judicious use is not legalized then patients
may start acquiring it from illegal ways, which might
lead to the poor quality and uncontrolled use opening
ways for more hazards than bringing the good.
10.
CONCLUSION:
Cannabinoids have been found useful in many
neurological and medical disorders. To keep its
use judicious and controlled, a frame work by the 11.
health authorities in collaboration with law
agencies should be made so that it might be
available when other hopes are lost and its use is
justifiable and only under a strict protocol. The
12.
three forces scientific knowledge, social and
political acceptance and legislation may help to
reach a consensus about its medicinal use.

PAKISTAN JOURNAL OF NEUROLOGICAL SCIENCES 54 VOL. 12 (3) JUL - SEP 2017


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